Provider Demographics
NPI:1467137125
Name:IBEAWUCHI, MORRIS
Entity Type:Individual
Prefix:
First Name:MORRIS
Middle Name:
Last Name:IBEAWUCHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 LONGSHORE AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19111-4538
Mailing Address - Country:US
Mailing Address - Phone:267-530-8372
Mailing Address - Fax:
Practice Address - Street 1:6970 GRAND CENTRAL PKWY
Practice Address - Street 2:
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-3949
Practice Address - Country:US
Practice Address - Phone:718-263-4600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY60-P122132-01207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine